RESEARCH

Adapted Physical Activity Quarterly, 2014, 31, 95-105

http://dx.doi.org/10.1123/apaq.2013-0068
© 2014 Human Kinetics, Inc.

Motor Skills and Calibrated Autism

Severity in Young Children With Autism
Spectrum Disorder
Megan MacDonald
Oregon State University

Catherine Lord
Weill Cornell Medical College and New York Presbyterian Hospital

Dale A. Ulrich
University of Michigan

In addition to the core characteristics of autism spectrum disorder (ASD), motor

skill deficits are present, persistent, and pervasive across age. Although motor skill
deficits have been indicated in young children with autism, they have not been
included in the primary discussion of eady intervention content. One hundred
fifty-nine young children with a confirmed diagnosis of ASD («=110), PDD-NOS
(« = 26), and non-ASD (n = 23) between the ages of 14-33 months participated
in this study.' The univariate general linear model tested the relationship of fine
and gross motor skills and social communicative skills (using calibrated autism
severity scores). Fine motor and gross motor skills significantly predicted cali-
brated autism severity {p < .05). Children with weaker motor skills have greater
social communicative skill deficits. Future directions and the role of motor skills
in early intervention are discussed.

Keywords: autism, motor skills, young children, calibrated severity

Autism spectrum disorder (ASD) is a pervasive developmental disorder char-

acterized by deficits in social skills, communication, and repetitive or restricted
interests (American Psychological Association [APA], 2013). The most recent
prevalence statistics suggest that 1 in 68 children are diagnosed with ASD (Centers
for Disease Control & Prevention [CDC], 2014). Standardized diagnostic tools
can identify children with autism as early as 1 year of age (Luyster et al., 2009).

Megan MacDonald is with the Exercise & Sport Science Program at Oregon State University in Corvallis,
OR. Catherine Lord is with Weill Cornell Medical College and also the New York Presbyterian Hospital in
White Plains, NY. Dale A. Ulrich is with the School of Kinesiology at the University of Michigan in Ann
Arbor, MI. Address author correspondence to Megan MacDonald at megan.niacdonald@oregonstate.edu.

95
96 MacDonald, Lord, & Ulrich

Unfortunately, the continuous rise in diagnosis makes autism one of the most
frequent childhood neurodevelopmental disorders and poses difficulty for service
providers in adhering to the concurrent increa.se in service needs (Downs & Downs,
2010; Fombonne, 2009; Matson & Kozlowski, 2011 ; Wise, Little, Holliman, Wise,
& Wang, 2010).
The most widely cited and recommended mode of treatment for the youngest
children with autism is early intervention focused on improving social communica-
tive skills (Dawson et al., 2010; Kasari et al., 2005; Kasari, Gulsrud, Wong, Kwon,
& Locke, 2010; NRC, 2001; Wong & Kwan, 2010). Successful early intervention
has resulted in children's improved IQ, language, adaptive behavior, play skills,
and autism diagnosis (i.e., moving from autism to pervasive developmental dis-
order - not otherwise specified [PDD-NOS]; Dawson et al., 2010; Kasari, et al.,
2010; Lovaas, 1987). Although there is widespread agreement on the necessity of
early intervention, best practice recommendations for early intervention are less
well defined, and there is less consistent agreement on specific program content
(Kasari et al., 2005). For example, social communicative skills may be targeted in
intervention using reading circles in a group-based format, while another successful
early intervention may u.se activities of daily living to focus on social communica-
tive skills. One potential content area that has been underexplored is the use of
motor skill development.
Children with ASD frequently have motor skill deficits that are present at a
young age (Lloyd, MacDonald, & Lord, 2013; Provost, Heimerl, & Lopez, 2007;
Provost, Lopez, & Heimerl, 2007). Traditionally the motor skill discussion of
children with ASD is focused on stereotypies and imitation; however, empirical
data has shown that motor skill deficits in children with autism range in nature and
across tasks (Landa & Garrett-Mayer, 2006; Lloyd et al., 2013; Staples & Reid,
2010; Vernazza-Martin et al., 2005). Empirical data has confirmed that early motor
skill delays are included in initial developmental concern to parents (Landa &
Garrett-Mayer, 2006; Lloyd, et al., 2013; Teittelbaum, Teittelbaum, Nye, Fryman,
& Maurer, 1998). In addition to delays in motor milestones deficits exist in gait,
postural control, and motor planning (Esposito & Venuti, 2008; Fahbri-Destro,
Cattaneo, Boria, & Rizzolatti, 2009; Lloyd et al., 2013; Vernazza-Martin et al.,
2005). Descriptive studies have clearly demonstrated significant motor skill deficits
in children with autism and even gone so far as to suggest motor skill deficits as a
preliminary diagnostic marker of ASD early in development (Landa, Gross, Stuart,
& Bauman, 2012; Teittelbaum et al., 1998).
Nevertheless, even though significant motor skill deficits are present in young
children with ASD the primary focus of early intervention is typically based on
improving social communication skills, a phenotypic characteristic of ASD. In
2001, a report from the National Research Council (NRC) indicated that motor skill
development should be emphasized in specialized early intervention curriculum
for young children with ASD. Yet, more than a decade later, early intervention
has not specifically targeted motor skill development (National Research Council
[NRC], 2001). Consequently, very little has been discussed in terms of how motor
skill deficits relate to the core characteristics of the disability in young children
with autism, children young enough to qualify for early intervention services. One
recent study identified a relationship between the motor skills of young children
with ASD and their respective adaptive behavior skills (MacDonald, Lord, & Ulrich,
 Motor Skills, Calibrated Severity, & ASD 97

2013a). Another study reported that motor skill deficits in school-aged children
with autism were related to calibrated autism severity scores, thus confirming
that a relationship exists between motor skill deficits and autism symptomology
(MacDonald, Lord, & Ulrich, 2013b). However, how this relationship, of motor
skills and calibrated autism severity, exists in much younger children with ASD
has not been explored.
The purpose of this study is to determine the relationship of motor skills and
the core behaviors of young children with autism, social affective skills and repeti-
tive behaviors, as indicated through the calibrated autism severity scores (Gotham,
Pickles, & Lord, 2009). It is hypothesized that children with better motor skills
will have better calibrated autism severity scores.

Method
Participants
The Institutional Review Board approved all methods and procedures for this
study and parents of the children consented to participation. Young children with
ASD, PDD-NOS, and non-ASD (developmental delay) between the ages of 12-33
months were recruited from early intervention studies and clinical referrals {n =
159). Generally, children were recruited through autism support groups, study
flyers, and referrals from pediatricians and teachers, and others were informed
of the research study when visiting the autism clinic. Children with non-ASD
(developmental delay) were included in this study to provide a range of scores
indicated through calibrated autism severity. All participants in this study had a
confirmatory diagnosis of ASD (« =110), PDD-NOS (« = 26), or non-ASD (« =
23). Diagnosis was determined by standardized algorithms established from the
Autism Diagnostic Observation Schedule (ADOS; Gotham, Risi, Pickles, & Lord,
2007; Lord et al., 2000).

Measurements
Developmental level. The Mullen Scales of Early Learning (MSEL) was used
to assess cognitive development (Mullen, 1995). This test of development provides
reliable and valid information for children from birth to 68 months of age. The
subscales of the MSEL are organized into 5 domains: gross motor, fine motor,
visual reception (nonverbal problem solving), receptive language, and expres-
sive language. All items are administered, observed, and scored by the assessor.
Majority of items are scored as either 1 (present) or 0 {not present/completed). A
standardized early learning composite score is derived from the fine motor, visual
reception, receptive language, and expressive language scales.
Motor skill measurement. The gross motor scale of the MSEL was used to assess
gross motor skills, and the fine motor scale of the MSEL was used to assess fine
motor skills (Mullen, 1995). This scale was administered in a clinical setting with
other developmental and diagnostic assessments at baseline. A gross motor and fine
motor standard score was used in analysis. Unfortunately, standardized scores do not
provide subscores below 20; therefore, age-equivalent scores were also described.
98 MacDonald, Lord, & Ulrich

Child diagnostic measures. All participants were administered the Autism

Diagnosis Observation Schedule (ADOS; Lord et al., 2000; Luyster et al., 2009)
to acquire diagnostic information through direct observation by a trained research
reliable clinician. Each member of the research clinical team established interrater
reliability exceeding 80% exact agreement (K > 0.60) on codes for the ADOS for
three consecutive administrations before the study began. Reliability was main-
tained over time through consensus coding; this occurred approximately every sixth
administration with a second rater who was blind to referral status. This method
of interrater reliability has been used previously (Gotham et al., 2009; Gotham et
al., 2007; Lord, 2000; Lord et al., 2000).
Autism symptomology. Calibrated autism severity scores were used to assess
autism symptomology. The ADOS is widely accepted as the criterion standard in
autism diagnosis (Lord et al., 2000; Luyster et al., 2009; Matson & Sipes, 2010).
The ADOS is a standardized assessment of social interaction, communication, play,
and the imaginative use of materials. The ADOS generates diagnostic algorithms
with thresholds set for autism and the broader autism phenotype (Lord et al., 2000).
Revised algorithms for the ADOS modules 1, 2, and 3 have been published with
stronger specificity and sensitivity (Gotham et al., 2007). Standardized scores of
calibrated severity are available using raw scores from the revised algorithms of the
ADOS (Gotham et al., 2009). Calibrated autism severity scores have been indicated
optimal for comparisons of assessments across time (and age) and to identify differ-
ent trajectories of autism severity independent of verbal IQ (Gotham et al, 2009).

Procedures
Assessments were typically administered in the aforementioned order. Develop-
mental level was assessed first to assist the administrator in choosing the appropriate
ADOS module (ADOS modules are based on the child's language level).

Data Reduction
All examiners strictly adhered to the standardized procedures outlined in each
respective test manual. As indicated in the measurement description of instruments,
research reliability and interrater reliability were established for the ADOS. The
MSEL was also administered to all participants, and each administration strictly
adhered to manualized protocols (Mullen, 1995). Descriptive scores from the
MSEL included an age difference score, which was calculated by subtracting the
gross motor and fine motor age equivalents score from the chronological age of the
participant. Standardized scores for the fine and gross motor scales of the MSEL
are standardized for children birth to 33 months. Standardized scores were used for
analysis in this study, as the sample consisted of children 33 months and younger.
A diagnosis of autism, PDD-NOS or non-autism, was obtained and reported based
on the participant's standard ADOS score (Lord et al., 2000; Luyster et al., 2009);
standard developmental levels are reported based on the measures of the MSEL
(Mullen, 1995). In addition, ratio verbal IQ and nonverbal IQ were calculated. Ratio
verbal IQ was calculated by taking the mean age equivalent of the expressive and
receptive language subtests, dividing by chronological age, and multiplying by 100.
Ratio nonverbal IQ was calculated in the same manner using the age equivalents
 Motor Skills, Calibrated Severity, & ASD 99

from the fine motor and visual reception subtests; this method has been used in
other studies (Lloyd et al, 2013).

Data Analysis
Data analysis tested the relationship of gross and fine motor skills measured by the
gross and fine motor scales of the MSEL, with autism symptomology as measured
by calibrated autism severity scores (Gotham et al., 2009; Gotham et al., 2007).
Data analysis was conducted in Statistical Package for the Social Sciences (SPSS)
version 16.0. The univariate general linear model (GLM; Garson, 2012) was used to
test the relationship of motor skills and autism symptomology. The univariate GLM
was chosen based on its ability to analyze fixed factors and covariates as predictors
(Garson, 2012). Age, nonverbal problem solving (as based on the visual receptive
organization subscale of the MSEL), gender, ethnicity, and autism diagnosis were
also included in the model.

Results
A total of 159 children with a confirmed diagnosis of ASD (« =110), PDD-NOS {n
= 26), and non-ASD (/¡ = 23) between the ages of 14-33 months were included in
this study (mean age = 27.6 months ± 4.6 months). A frequency analysis revealed a
high proportion of the sample scored within the basal norm range (a standard score
of 20). Of the sample, 50.7% scored the basal norm of the gross motor scale and
24.5% scored within the basal norm range of thefinemotor scale. Based on skewed
gross and fine motor skill distributions, a visual binning analysis was conducted
for the gross motor scale and the fine motor scale, respectively. The visual binning
analysis created three distinct categorical variables—low, medium, and high—based
on motor skill standard score distribution. This visual binning analysis used SPSS
version 16.0 automatic options.
Average age equivalent scores are reported for all scales of the MSEL, along
with descriptive characteristics of the sample (Table 1). For descriptive purposes,
a gross and fine motor difference variable was calculated. The variable quantifies
the amount of motor delay in months, regardless of chronological age. Based on
the age difference calculation, children were performing 6.4 months behind the
norm-referenced gross motor skills and 9.5 months behind the norm-referenced
fine motor skills of typically developed children.

Influence of Gross Motor Skills on Calibrated Autism Severity

The univariate GLM tested the relationship of categorical gross motor skills
(grouped into categories of low, medium, and high) and calibrated autism severity.
Nonverbal problem solving, age, gender, ethnicity, and diagnosis were included
in the model. There were no interactions. Results indicated that gross motor skills
were related to calibrated autism severity (p < .05, r|- = 0.02). This model also indi-
cated that diagnosis (p<.OO\,ii]^= 0.71), age (/? < .001, -p^ = 0.03), and nonverbal
problem solving (p < .01, r|- = 0.01) were predictors of calibrated autism severity.
The final model indicated that children with lower gross motor skills had a higher
calibrated autism severity.
 100 MacDonald, Lord, & Ulrich

Table 1 Descriptive Characteristics of the Participants

Variable Mean/Frequency
Age (months) 27.63 (4.6)*
Gender 125M, 34F
Race/ethnicity 108 Caucasian, 48 African American, 1
Native American, 1 biracial, I unspecified
Maternal education 23 graduate/ professional, 42 college, 44
some college, 28 high school diploma, 2
some high school education, 20 unspecified
Autism diagnostic classification 110 ASD, 26 PDD-NOS, 23 non-ASD
Age-Equivalent Gross Motor Subtest 21.23(6.1)
Age Equivalent Fine Motor Subtest 18.11 (5.7)
Age Equivalent Visual Reception Subtest 19.12(6.4)
Age Equivalent Receptive Language Subtest 9.67 (7.0)
Age Equivalent Expressive Language 10.35 (5.8)
Subtest
Ratio verbal IQ 37.2 (22.6)
Ratio nonverbal IQ 68.7(21.4)
Note. N = 159. *Mean (standard deviation)

Influence of Fine Motor Skills on Calibrated Autism Severity

The univariate GLM tested the relationship of categorical fine motor skills (grouped
into categories of low, medium, and high based on a visual binning analysis) and
calibrated autism severity. Nonverbal problem solving, age, gender, ethnicity, and
diagnosis were included in the model. Fine motor skills were significant predictors
of calibrated autism severity (/? < .01, Ti" = 0.02), there were no interactions. This
model also indicated that diagnosis was a predictor in calibrated autism severity (p
< .001, r|- = 0.74). This final model indicated that children with lower fine motor
skills had a higher calibrated autism severity.

Discussion
Thefineand gross motor skills of young children with autism ( 12-33 months) were
related to calibrated autism severity. Children with lower fine and gross motor skills
had higher calibrated autism severity scores, indicating more behaviors specific
to autism symptomology. Given the young age range of the participants in this
study, motor skill deficits arc substantial. Fine motor skill deficits were 9.5 months
behind chronological age, and gross motor skill deficits were 6.4 months behind
chronological age. The relationship of motor skills and calibrated autism severity
held constant nonverbal problem solving. In other words, this relationship is not
driven entirely by intellectual ability. Motor skills were an independent predictor
 Motor Skills, Calibrated Severity, & ASD 101

of calibrated autism severity. Although effect sizes were small for both fine and
gross motor skills (both at r|- = 0.02), the majority of the variance was explained
by diagnosis (based on DSM-IV-R criteria); however, this would be expected, as
indicated in the creation of the calibrated autism severity scores (Gotham et al.,
2009). Thus, even a small relationship provides new insight into potential content
mechanisms for early intervention.
In a similar study, the motor skills of school-aged children with autism were
predictive of calibrated autism severity (MacDonald et al., 2013b). MacDonald
et al. found object-control skills (motor skills), as measured by the Test of Gross
Motor Development - 2nd Edition (Ulrich, 2000), were related to calibrated autism
severity, as indicated through standardized algorithms (Gotham et al., 2009).
School-aged children with better object-control skills—such as overhand throwing,
striking, kicking, underhand rolling, dribbling, and catching—had better calibrated
autism severity scores.
To our knowledge, this study is the first to show a direct relationship between
motor skills and calibrated autism severity scores in young children with autism.
It has been suggested that better motor skills early in life could provide a solid
foundation for the components of early intervention, social communicative skills,
to manifest positively (Lloyd et al., 2013; Sutera, Pandey, Esser, & Rosenthal,
2007). In other words, better motor skills early in life could provide children with
the foundational skills needed to move toward an optimal outcome—yet this theory
has not been studied directly. Both cognitive and motor skill performance have
been recognized as indicators of positive prognosis (Helt et al., 2008; Landa et al.,
2012; Sutera et al., 2007), yet rehabilitation focused on improving motor skills has
been relatively limited. There is a need for well-controlled motor skill-based early
interventions for young children with ASD.
Although the modality of early intervention varies, the basis of early interven-
tion focuses on teaching social communicative skills through active play (Dawson
et al., 2010; Kasari, Paparella, Freeman, & Jahromi, 2008; Rogers, Hall, Osaki,
Reaven, & Herbison, 2000). Early intervention is focused on "active play," and
motor skills are influential in the functional performance of play (Dawson et al.,
2010; Lloyd et al., 2013; Makrygianni & Reed, 2010). Early motor skill deficits
have been acknowledged as indicators of early diagnosis (Teittelbaum et al., 1998),
positive prognosis (outcome; Sutera et al., 2007), and motor skills often are used as
inclusion criteria for early intervention programs (e.g., children need to be walk-
ing). Beyond acknowledging occupational and physical therapy, movement-based
early interventions or rehabilitation programs focused on improving motor skills
for these young children are underexplored (Lloyd et al., 2013; Provost, Heimerl
et al., 2007; Provost, Lopez et al., 2007).
It is not surprising that early intervention is focused on social communica-
tive skills, given the phenotypic characteristics of autism; however, it is possible
that motor skill deficits are hindering success (Sutera et al., 2007). In this study,
a large diagnostic sample of young children with autism and non-autism indicate
strong relationships between motor skills and autism symptomology based on the
predictive validity of gross and fine motor skills on calibrated severity. These find-
ings provide a solid foundation to further explore how this relationship manifests
and ultimately how motor skill rehabilitation can be further integrated into early
interventions for young children with autism.
102 MacDonald, Lord, & Ulrich

Motor deficits are gaining recognition as a phenotypic characteristic of autism,

potential diagnostic marker, and influential in autism prognosis (Fournier, Hass,
Naik, Lodha, & Cauraugh, 2010; Sutera et al, 2007; Teittelbaum et al., 1998).
Behavior-driven research has suggested relationships between motor skills and
autism symptomology, speculating that motor skills could hinder success in early
intervention (Lloyd et al., 2013; Sutera et al., 2007). Future studies need to address
this relationship further. Although calibrated severity is relatively stable (Gotham et
al., 2009), we see positive developmental trajectories in very young children with
ASD (Dawson et al., 2010; Ozonoff et al., 2010; Ozonoff et al., 2008; Yirmiya &
Ozonoff, 2007). Implementing successful interventions targeted at improving basic
motor skills may further assist children toward improved autism symptomology.
In addition, early intervention focused on motor skill development may help to
establish functional play skills necessary for age-related "play-based" activities.
Better motor skills may help young children obtain the participation opportunities
to play skill-based games and activities, as well as social communicative practice.

Limitations
A limitation of this study is the use of the MSEL to measure motor skills. A more
sensitive motor skill measure may have provided better motor skill data. However,
the MSEL is commonly used in clinical assessments and is a valid and reliable
measure of gross and fine motor skills.

Conclusion
Establishing effective strategies to improve symptomology in young children with
autism is a priority in autism research (Kasari et al., 2(K)5; Yirmiya & Ozonoft, 2007).
Dawson et al. (2010) were thefirstgroup to conduct a well-controlled randomized
control trial of early intervention for toddlers with ASD. Dawson et al. (2010) provided
clear evidence that early intervention improves IQ, language, adaptive behavior, and
autism diagnosis. The results of the cuiTent study suggest that there is more to focus
on and new avenues to explore in the realm of discovering how to implement early
intervention and rehabilitation for young children with autism. Our study demon-
strates a direct relationship between motor skill deficits and autism symptomology,
as indicated through calibrated autism severity. In such a young group of children,
motor skill deficits are equivalent to a major proportion of the children's lifespan (i.e.,
a 9-month deficit in a young children of' 24 months of age is proportionately more
than a 9-month deficit in an older children with autism). This is an area of concern
and unfortunately an area of neglect (Rosenbaum, 2005). In this descriptive study,
motor skills are predictive of severity; yet at a young age, autism severity has an
opportunity to improve, albeit with the appropriate intervention techniques.

Acknowledgements
Dr. Lord receives royalties from Western Psychological Service for the sale of diagnostic
instruments that she has coauthored. Dr. Lord donates all royalties from these projects and
clinics to not-for-profit autism charities, specifically Have Dreams, which is located in
Chicago, Illinois. Have Dreams offers wraparound services for children and adults with
autism. Drs. MacDonald & Ulrich have no disclosures.
 Motor Skills, Calibrated Severity, & ASD 103

Financial Disclosures
Support for this project was provided in part from funding awarded to Dr. Lord from the
Simons Foundation, First Words, and the following grants: NICHD U19 HD35482-01. The
Neurobiology and Genefic of Autism. 06/01/97-05/31/07 (Lord). NIMH ROl MH081873-
OlAl. Longitudinal Studies of Autism Spectrum Disorders: 2 to 23. 09/01/08-05/31/13
(Lord). Blue Cross Blue Shield Foundation of Michigan Grant Motor skills, calibrated
severity & autism number 1687.SAP (MacDonald).

Note
1. Data for this project were collected before the DSM-V was published in 2013. Thus, the
authors included ASD subcategories, as they existed in the DSM-IV R.

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